Type 2 Diabetes Performance Improvement Initiative: Chart ... ?· Performance Improvement Initiative:…

Embed Size (px)

Text of Type 2 Diabetes Performance Improvement Initiative: Chart ... ?· Performance Improvement...

  • 1

    Type 2 Diabetes Type 2 Diabetes Performance Performance

    Improvement Initiative:Improvement Initiative:Chart ReviewsChart Reviews

    Lara ZisblattLara ZisblattBoston University School of Boston University School of

    MedicineMedicineBoston, MABoston, MA

    22

    Participants in the ProgramParticipants in the Program

    487 people registered487 people registered

    217 people started the program217 people started the program

    182 people started their initial chart review182 people started their initial chart review

    35 people completed their initial chart 35 people completed their initial chart reviewreview

    22 people are working on their Action Plans22 people are working on their Action Plans

    3 people completed the program3 people completed the program

    33

    Examples of Action PlansExamples of Action Plans

    Screening all medical records for patients with type 2 diabetes Screening all medical records for patients with type 2 diabetes every 6 months and notifying them by phone if they need an A1C every 6 months and notifying them by phone if they need an A1C testtest

    Creating an exercise plan worksheet for patients to write out Creating an exercise plan worksheet for patients to write out their exercise planstheir exercise plans

    Providing patient education about the importance of selfProviding patient education about the importance of self--monitoring blood glucose levels; training the medical assistant monitoring blood glucose levels; training the medical assistant to check all meters to assure they are working properly and thatto check all meters to assure they are working properly and thatpatients know how to use thempatients know how to use them

    Enrolling all type 2 diabetes patients in an education class Enrolling all type 2 diabetes patients in an education class available at the practiceavailable at the practice

    Creating a registry of all patients with type 2 diabetes that woCreating a registry of all patients with type 2 diabetes that would uld track all tests necessary for these patientstrack all tests necessary for these patients

    Use the diabetes care form to keep good records of patients withUse the diabetes care form to keep good records of patients withtype 2 diabetes and an excel form to track patientstype 2 diabetes and an excel form to track patients

    Routine prescription for exerciseRoutine prescription for exercise Diabetes flow sheets in all charts Diabetes flow sheets in all charts Will move educational materials to exam roomsWill move educational materials to exam rooms

  • 2

    44

    Action PlansAction Plans

    Start simpleStart simple

    Small changes can mean big improvements in patient Small changes can mean big improvements in patient carecare

    Chart review is the first stepChart review is the first step

    The tough part was getting started. Once I did The tough part was getting started. Once I did the first chart review, every review after became the first chart review, every review after became easier and faster.easier and faster.

    The chart review was a great way for me to The chart review was a great way for me to systematically look at my practice. I could see systematically look at my practice. I could see how I was actually doing and not just how I how I was actually doing and not just how I thought I was doing.thought I was doing.

    55

    Type 2 Diabetes ProgramType 2 Diabetes Program

    Make a commitment to yourself and to your Make a commitment to yourself and to your patients to work toward improving care!patients to work toward improving care!

    Complete the chart review as soon as possible Complete the chart review as soon as possible as your first step toward improvementas your first step toward improvement

    For those of you who have completed chart For those of you who have completed chart reviews, please feel free to call us if you would reviews, please feel free to call us if you would like to discuss your plan for improvementlike to discuss your plan for improvement

    If you have any questions, please email us at If you have any questions, please email us at mentorqi@bu.edumentorqi@bu.edu or call us at or call us at 617.638.4605617.638.4605

    Applying What WeApplying What Weve ve Learned:Learned:

    Patient Case Studies Patient Case Studies (Part 1)(Part 1)

    Elliot Sternthal, MDElliot Sternthal, MDClinical Director, Diabetes Services Clinical Director, Diabetes Services

    Boston Medical CenterBoston Medical CenterBoston, MABoston, MA

  • 3

    Mr. DMr. D

    6969--yryr--old maleold male

    1111--yr history of type 2 DMyr history of type 2 DM

    Mild retinopathy, distal neuropathy, Mild retinopathy, distal neuropathy, microalbuminuriamicroalbuminuria, obesity, , obesity, coronary artery disease, hypertension, hypercholesterolemia, coronary artery disease, hypertension, hypercholesterolemia, dyslipidemiadyslipidemia, erectile dysfunction, erectile dysfunction

    Current medication regimen:Current medication regimen:

    GlipizideGlipizide ER 10 mg ER 10 mg qdqd, , metforminmetformin 1000 mg BID, HCTZ 25 1000 mg BID, HCTZ 25 mg mg qdqd, , valsartanvalsartan 160 mg 160 mg qdqd, , cardizemcardizem CR 120 mg CR 120 mg qdqd, , ASA 325 mg ASA 325 mg qdqd, , atorvastatinatorvastatin 20 mg 20 mg qdqd

    Pertinent physical examination findingsPertinent physical examination findings

    BMI 37, BP 114/58, rare retinal BMI 37, BP 114/58, rare retinal microaneurysmsmicroaneurysms, , vibratory perceptionvibratory perception

    88

    Mr. D Mr. D (cont(contd)d)

    SelfSelf--care behaviorscare behaviors

    SelfSelf--monitoring of blood glucose (SMBG): monitoring of blood glucose (SMBG): erratic, usually erratic, usually premealpremeal BG >200 mg/BG >200 mg/dLdL

    Dietary: limited adherence, likes starches, Dietary: limited adherence, likes starches, occasional binges occasional binges

    Physical activity: walking at moderate Physical activity: walking at moderate pacepace

    Lab dataLab data

    A1C 8.8%; mean FBG ~180; mean 2A1C 8.8%; mean FBG ~180; mean 2--hr hr PBG >240PBG >240

    99

    What Are the Clinical Challenges What Are the Clinical Challenges With This Patient?With This Patient?

  • 4

    Clinical challenges: Clinical challenges: Improve preImprove pre-- & postprandial BGs, & postprandial BGs, promote weight loss, prevent recurrent CV eventspromote weight loss, prevent recurrent CV events

    Desired treatment goals: Desired treatment goals:

    PreprandialPreprandial BG 90BG 90--130, 2130, 2--hr pp BG 100hr pp BG 100--140, 140, A1C 7% (? 6.5%)A1C 7% (? 6.5%)

    BP 130/80 mm HgBP 130/80 mm Hg

    LDL 40, TG

  • 5

    1313

    Medication Addition:Medication Addition:What Are The Pros and Cons?What Are The Pros and Cons?

    Add a Add a thiazolidinedionethiazolidinedione (TZD)?(TZD)?

    Add an alphaAdd an alpha--glucosidaseglucosidase inhibitor?inhibitor?

    Add a DPPAdd a DPP--4 inhibitor?4 inhibitor?

    Add Add exenatideexenatide??

    ExenatideExenatide AddedAddedEffect on overall glycemic control: Effect on overall glycemic control:

    A1C to 7.1% after 3 monthsA1C to 7.1% after 3 months

    Effect on postprandial glycemia: Effect on postprandial glycemia: 70 mg/70 mg/dLdL

    Weight effect: Weight effect: 8 lb8 lb

    1515

    Ms. CMs. C

    Recently immigrated to US; speaks rudimentary English

    Lives with a cousin, works in housekeeping in a hotel

    Recently diagnosed type 2 DM at walk-in clinic: random BG 255

  • 6

    1616

    Ms. C Ms. C (cont(contd)d)

    Pertinent physical examination findingsPertinent physical examination findings Wt 216, Ht 5Wt 216, Ht 566, BMI 35, BP 140/82, BMI 35, BP 140/82

    Marked Marked acanthosisacanthosis nigricansnigricans and facial acneand facial acne No retinopathy or neuropathyNo retinopathy or neuropathy

    SelfSelf--care behaviorcare behavior Little knowledge of diabetes or dietLittle knowledge of diabetes or diet No SMBGNo SMBG No exercise: too tired; works 50 hrs per weekNo exercise: too tired; works 50 hrs per week

    1717

    Ms. C Ms. C (cont(contd)d)

    Lab DataLab Data

    A1C 9%; urine A1C 9%; urine microalbuminmicroalbuminratio 10ratio 10

    Hypercholesterolemia: LDL Hypercholesterolemia: LDL 122, HDL 57, TG 215122, HDL 57, TG 215

    1818

    What Are the Clinical Challenges What Are the Clinical Challenges With This Patient?With This Patient?

  • 7

    Clinical Challenges: Clinical Challenges: Lack of diabetes educationLack of diabetes education

    Goals:Goals:Nutrition counseling for Nutrition counseling for hyperlipidemiahyperlipidemia, weight loss, weight lossTeaching SMBG, DSMETeaching SMBG, DSME

    Potential barriers to successful treatment:Potential barriers to successful treatment: Language/medical literacyLanguage/medical literacy Cultural/social beliefsCultural/social beliefs Economic concernsEconomic concerns Comprehension of her illness and treatmentComprehension of her illness and treatment Complex treatment programComplex treatment program Medication side effectsMedication side effects

    2020

    Desired treatment goals: Desired treatment goals:

    PreprandialPreprandial BG 90BG 90--130, 2130, 2--hr pp BG 100hr pp BG 100--140; A1C 6.5%140; A1C 6.5%--7%7%

    BP 130/80 mm HgBP 130/80 mm Hg

    LDL 50, TG

  • 8

    2222

    Initial PlanInitial Plan

    Start combination Start combination glyburideglyburide 1.25 1.25 mg/mg/metforminmetformin 250 mg 250 mg qamqam

    ASA 81 mg ASA 81 mg qdqd??

    2323

    FollowFollow--Up:Up:3 months3 months

    A1C 8.3%A1C 8.3%PrePre--breakfast BG 140breakfast BG 140--207207PrePre--dinner